UK HealthCast: Understanding the work of 'ear, nose and throat' specialists

UK HealthCast is a podcast series featuring interviews with UK HealthCare experts on a variety of health-related topics.

Otolaryngology, more commonly referred to as “ear, nose and throat (ENT),” focuses on diseases of those organs as well as other illnesses and injuries in the neck area.

In this edition of UK HealthCast, Dr. Rachel Jonas, an otolaryngologist specializing in laryngology, shares an overview of what she does.

Listen to the conversation below. For an edited transcript of the conversation, continue reading.

Host: In a nutshell, what does an otolaryngologist do and how does your subspecialty fit into that?

Dr. Jonas: Otolaryngology is more commonly known as Ear, Nose and Throat or ENT. And once you kind of break it down to ears, nose and throat, it's kind of tells you a lot. So an otolaryngologist focuses on the diseases of the ears, the nose, the throat, and then also we focus on anything going on in the neck area.

So there are some subspecialists who focus on thyroid, neck cancer, etc. But me specifically, I focus on the throat aspect of ear, nose, and throat. Laryngology is the larynx specifically. 

Anything dealing with the larynx, which has to do with breathing, has to do with the voice and has to do with swallowing. I focus on difficulty with voice, difficulty swallowing and difficulty breathing.

Host: What first inspired you to pursue a career in medicine and why ENT and laryngology specifically? 

Dr. Jonas: I was actually a teacher before I went to medical school, and a lot of my interactions with my students and my students' parents and hearing about their health issues, and feeling like a lot of times my students weren't coming to school because of their health issues or their family's health issues, actually is what led me into medicine.

I noticed two things within ENT. One, it really focused on human interactions and what gives meaning to our life. Being able to talk and communicating. Being able to hear, being able to sit down and have a meal with someone. That's really what ENT focuses on is really giving quality and meaning to life. 

And then the really cool thing about ENT is that we have a lot of collaboration. So for example, the folks who specifically focus on the ears, they're always working with the audiologists. I'm always working with the voice therapist and the swallow therapist and really trying to come up with a multidisciplinary approach to treat patients and optimize their outcomes.

Host: What voice, airway and swallowing conditions do you typically treat? What's most common?

Dr. Jonas: A lot of people present to me with chronic hoarseness, feeling like their voice doesn't sound the same. There can be a wide range of reasons for this. Sometimes it's a functional thing, the way patients are using their voice, especially after an injury or something like a laryngitis, and then they just kind of start using their voice incorrectly and need some voice therapy to do that or to improve their voice. 

Then there can be lesions on the vocal chords. There can be growths, there can be paralysis of the vocal chords. Those are really the main reasons for dysphonia.
Host: When you talk about people suffering from that, what are the most common ways in which perhaps people damage their voice without even realizing it?

Dr. Jonas: Good question. That's hard to know because hindsight's always 20/20. Sometimes, you can have a prominent vessel on your vocal cord and that vessel can rupture and cause a hemorrhage. Sometimes it's from overuse, yelling, and then that causes nodules on the vocal cords. A lot of times it's from smoking. Smoking can cause growths on the vocal cords. And then sometimes we just don't know what caused the damage.

Host: When exactly would you say that someone should seek help from a professional, a specialist like yourself, if they notice voice or swallowing issues? 

Dr. Jonas: Our practice guidelines recommend that someone have a laryngoscopy, which means looking at the voice box, if the voice has not improved after four weeks. So that's pretty early on. If you've had hoarseness for four weeks, our guidelines do recommend getting into see a laryngologist or an ear, nose and throat doctor who can look at the voice box in clinic and evaluate.

So that's, in terms of the voice, I would recommend pretty early evaluation. In terms of swallowing, I think we're looking for red flag symptoms, which prompts urgent evaluation and then, if you don't have any of those red flag symptoms, we start saying, really it's symptoms. How much is this bothering you?

How much is this impacting your quality of life? How much is this preventing you from being able to enjoy a meal with your family? One of those red flag symptoms is excessive weight loss. You need a pretty urgent evaluation. The other one is pneumonia. If you're having a pneumonia because of your difficulty swallowing, that means food is going down into your lungs and you're having aspiration events.

Weight loss and pneumonias are really the big ones where I say urgent evaluation, and then after that it becomes really how much is this impacting your quality of life?

Host:  Anything further that people should know when they come in to be checked out?

Dr. Jonas: I'm always going to look at your throat with what's called a flexible laryngoscope. The main way of doing that is actually with this small little camera. It looks like a thin piece of spaghetti that has a camera on the end and it goes actually in through the nose cause the nose is connected to your throat as you can imagine, because you breathe through your nose and then you get air into your throat and then into your windpipe.

So the camera goes into the nose, goes all the way through the nose, and then it makes this little curve down to look at the throat. And then we can see the voice box and we can see the start of where you swallow. We can't actually see the esophagus, but we see the start of where you swallow. While we're looking at the voice box, we ask you to say words.

We ask you to make sounds, and so that we can see the vocal cords, not only just their anatomy, make sure there's nothing on them, but then see how they're functioning. Make sure they're vibrating correctly, make sure they're moving correctly. So that's for difficulty breathing. For difficulty swallowing, one of the main things I get is called a barium swallow study. That's where you go and you sit in an x-ray machine and you drink barium. Barium shows up on x-rays so you can watch it go down the esophagus and we can watch where the barium might be getting stuck or if there's any strictures, anything that's preventing the flow of barium.

We can also look at the strength of the muscles and see how the throat muscles are working to make sure that that is efficiently using your muscles and your swallowing mechanisms as well.

Host: What are some of the in-office procedures you're able to perform in terms of treatment and when necessary, what surgical procedures are performed?

Dr. Jonas: Your vocal chords are kind of like curtains. They open and close. They open when air goes through them and air goes down into your lungs. They close when you talk, and then they vibrate against each other. If one of the vocal cords isn't able to open or close, then the vocal cords can't touch in the middle and then they can't vibrate. 

This paralysis of the vocal cords causes people to have a really breathy voice. One thing we can do in the office is we can actually go and we can put filler in their vocal cords, and that makes the vocal cord bigger, and then it will touch the other vocal cord and it will improve the voice.

There are also a range of laser procedures that I can do. If people have growths on their vocal cords, we can ablate it with a laser and that can be done in the office. We can also inject steroids, inject lots of other things into the throat in the office. 

In terms of swallowing, the in-office procedure that we can do as a dilation. Now, I typically do my dilations in the operating room just because of patient tolerance. It is a little bit uncomfortable. But there are some patients who are really champs and don't want to undergo general anesthesia, and they can tolerate an in-office dilation really well. It's where we put a balloon into the upper esophagus and inflate that balloon and it just dilates, and opens up the esophagus.

Host: And then in terms of working closely with other specialists and speech language pathologists at UK HealthCare, what would you say the key is to making that all work?

Dr. Jonas: Communication, always communication. 

The swallow therapist and the voice therapist and I are constantly talking about patients and talking about our plans, our thoughts. We oftentimes show our scope exams to each other and just relay progress that patients are making. So if I have a patient who I think needs voice therapy, but they're just not making progress with the voice therapist; the voice therapist will contact me and say, is there anything surgically or procedurally that you can do? 

Similarly, if I see a patient who I think is using their vocal cords in an inefficient manner and needs a little bit of therapy to readjust and reuse their voice in a more efficient way, then I'll contact the voice therapist.

Host: For professionals that rely heavily on their voice to make a living — singers, teachers, people that have to speak a lot for whatever reason — what's the biggest recommendation you'd give them for keeping their voice healthy?

Dr. Jonas: Well, one, avoid smoking and being around secondhand smoke. That not only dries out the membranes of the mucosal membranes of the vocal cords, but it risks growths on the vocal cords. So avoiding smoking, avoiding secondhand smoking is the number one recommendation that I have. 

After that, it's humidification. Humidification can really help with the lining of the vocal cords. So that means drinking a lot of water. If you're going to be in a dry place, have a humidifier with you. 

And then I always tell patients, if you're struggling with your voice, instead of pushing it out, get an amplifier. Sometimes just a microphone if you're a teacher in the classroom and you're feeling like you're really straining to use your voice and students aren't hearing you; then get a microphone and that prevents strain on the vocal cords.

Host: Sounds like great advice. How about one common misconception or just one thing you wish from your experience that more people knew about the work you do or about voice and airway health in general?

Dr. Jonas: I wish more people knew how beneficial a voice therapist can be. 

Oftentimes, I tell patients that they need voice therapy and they're just looking for a quick fix, a quick medication or a surgery or something, and are not as invested in undergoing voice therapy, which can be about a one to two month process. I do wish that patients really realize the benefit of voice therapy and, working alongside a voice therapist as well as your doctor.